By Nancy Collar
When I saw the email announcing a new job opening for lung navigator, I was immediately interested. Even though it was initially a temporary position, the challenge intrigued me. The job announcement was somewhat vague, but the possibilities and opportunity excited me. My mind immediately starting thinking of all the ways I could help navigate our lung patients, especially along the lines of education.
I have been a respiratory therapist for 38 years and have worked at Inova Fairfax Hospital in Falls Church, VA, for 36 of them. I have experience in every inpatient area of our respiratory department, including NICU, PICU, air and ground transport, trauma, cardiovascular, ED, ECMO, research, education, and management. I also have experience in home health care.
However, I did not have much experience in our outpatient areas of pulmonary rehabilitation, pulmonary diagnostics, and interventional pulmonology (IP), so this job peaked my interest, especially as a lifelong learner.
Decreasing time to first appointment
The position was called “lung navigator” and I would be working directly with our interventional pulmonologist, Bobby Mahajan, MD, FCCP, DAABIP. Interventional pulmonology was a new area for our respiratory care department and learning something new excited me.
Dr. Mahajan was performing advanced procedures to identify lung cancer at the earliest stage possible. In addition, he was an expert at treating critical airways. It seemed this new IP section was always doing new and exciting things and they were staffed 100% by respiratory therapists! An opportunity to use my knowledge as a respiratory therapist, my 38 years of experience in the field, and my desire to think outside of the box was just what I was looking for.
Pioneering a position that is historically filled by nurses and is normally oncology-focused was exciting to me. Being able to develop programs from scratch was a challenge I was thrilled to take. The initial direction I was given was to decrease the time from lung cancer diagnosis to first oncology appointment.
We are privileged to have cytology technicians readily available to assist Dr. Mahajan during bronchoscopies, so lung samples could quickly be identified as malignant or benign. After the procedure, I introduced myself to the patient in the recovery area and informed the patient I would be contacting them the following day to discuss next steps. This immediate contact put the patients at ease. I was able to quickly set up their first appointment with an oncologist, even before the official pathology report was finalized.
Another program gears up
Next, I was tasked with developing an Incidental Lung Nodule (ILN) Program. Another opportunity to learn, while applying the critical thinking skills I had gained from my years as an RT.
I attended lectures and educated myself on all things lung cancer, networked with other hospitals with ILN programs, and partnered with MedTronics, who was coming out with a software program that mines radiology exams for ILN.
However, since it would be months before we would have this software available for my use, I began looking into how I could query our electronic medical record (EMR) radiology reports now. I worked with our radiology department to write a report that queries specific words used in the radiologist’s interpretation of all radiology exams performed on patients coming through our emergency department. I collaborated with our pulmonary section physicians to develop an algorithm, based on Fleischner Criteria, to direct these patients for follow-up care.
I worked with our legal and compliance teams to develop letters that would be mailed to patients regarding the ILN finding and recommended follow-up. I partnered closely with our emergency room physicians to understand how patients were currently notified of an ILN finding. I met with the radiologists to improve on the verbiage they use in their interpretation, with emphasis on using key words and the size and location of the ILN. I worked with our language department to have the letters translated into the eight main languages spoken in our region. I also set up a database to track all this data.
After just a few weeks in the position, I began running this report, tracking data, making phone calls to patients, mailing letters, and producing quality reports. Within our first 12 months, we had identified almost 1,000 incidental lung nodules, some of which were early stage cancers. Treatment was quickly obtained and some of these patients are now cancer free.
A new option for better breathing
Another program I was tasked with starting is the Bronchoscopic Lung Volume Reduction (BLVR) Program. This program targets our emphysema patient population with specific pulmonary function test (PFT) results, namely severe hyperinflation.
I educated myself about all things BLVR, attended training at Temple University, and began developing our program alongside Dr. Mahajan. We began receiving referrals from our local pulmonologists. We developed a referral form, which included the inclusion criteria used in the most recent BLVR studies.
Because this procedure was just approved by the FDA in the third quarter of 2018, it was still new to many. We quickly had referrals coming in from all over the Commonwealth of Virginia and Maryland. Patients were excited about this new option for “better breathing.”
We identified our first patient and quickly realized our need for constant re-evaluation of the criteria in order to target the patients who would be the best candidates and receive the most benefit from this cutting-edge therapy. We realized the benefit of pulmonary rehabilitation (PR) and quickly made this a mandatory component of our program, both pre- and post-procedure. The partnership with our PR program has been exemplary. With PR truly being a frontline treatment for COPD, the value for this patient population is immeasurable.
We designed written materials about the procedure and criteria for both physicians and patients. We designed referral forms, patient intake forms, and physician communication tools. We created a monthly collaborate practice BLVR Quality Team that meets and reviews patients pre-operatively, as well as tracks our post-op testing results. This collaboration allows us to constantly ensure we are targeting the best patients who will receive optimal results, as well as ensure we are adjusting our program, as indicated, by our data.
Much of my day is spent talking to patients who desire better breathing. I am able to spend as much time as they need to help them understand this cutting-edge procedure, but also emphasize the normal actions they must incorporate into their daily life with emphysema — inhaled medications and exercise! We also focus a lot on nutrition and water intake. Because this patient population is at the highest risk for both mortality and morbidity, it is imperative that they understand things they can do to make their quality of life and breathing better.
Right for the job
Even within the field of respiratory therapy, there are only a handful of RT navigators across the country. Most of them focus exclusively on emphysema. While our department is looking to add this type of navigator, the lung navigator role I am in was created to be a little more broad, encompassing both emphysema and lung cancer; a nice mixture of the traditional nurse oncology navigator role and the new RT navigator role.
The benefit of having a respiratory therapist as a navigator is the expertise this field brings to lung disease. RTs have advanced training in the physiology of the lungs as well as the heart, and the integration that all body systems have with breathing. Multiple hours are spent learning and perfecting skills related to airway management, airway clearance, airway optimization, and advanced breathing. Critical thinking skills are a must in the field of respiratory therapy and putting all the pieces of the puzzle together is not optional.
Additionally, because technology is constantly changing, RTs must have a passion for learning and always be looking for the best way to treat their patients with lung disease or breathing problems. They possess hands on skills and a full tool belt of options to open airways, clear them, protect them, and make them stronger. Their job spans from birth to death, from home care to intensive care, from diagnostics to procedures, and from paralyzed patients to teaching PR patients how to improve their lung strength.
RTs rock and I LOVE MY JOB!
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